Chapter 67

Musculoskeletal Trauma and Orthopedic Surgery Notes

Public Education and Safety Precautions

  • Public education is critical in reducing the risk of musculoskeletal injury and morbidity.

  • Recommended safety precautions include:

    • Wearing seat belts.

    • Following speed limits while driving.

    • Avoiding distracted driving.

    • Not driving under the influence of alcohol or drugs.

    • Warming up before exercising.

    • Using protective athletic equipment for sports.

    • Using proper safety equipment at work.

Preventive Teaching for High-Risk Persons

  • Target individuals with:

    • Gait instability.

    • Vision impairment.

  • Recommendations include:

    • Ensuring adequate intake of calcium and vitamin D for bone health.

    • Assessing the living environment for safety risks.

  • Precautionary measures:

    • Wearing functional, nonskid, hard-soled shoes.

    • Removing throw rugs to prevent trips.

    • Ensuring adequate lighting in living spaces.

    • Maintaining a clear path to the bathroom for nighttime use.

    • Avoiding walking on uneven or wet surfaces.

Soft Tissue Injuries Overview

  • Soft tissue injuries include:

    • Sprains: Injury to ligaments around a joint, classified as mild, moderate, or severe based on the extent of ligament damage.

    • Strains: Excessive stretching of muscle and fascia, which may involve tendons; classified similarly to sprains.

    • Dislocations and subluxations: Complete or partial displacement of joint surfaces.

  • Common sports-related injuries include:

    • Impingement syndrome.

    • Rotator cuff tear.

    • Shin splints.

    • Tendonitis.

    • Ligament injuries.

    • Meniscus injuries.

    • Anterior cruciate ligament (ACL) tear.

Sprains and Strains

  • Sprain Definition: Injury to the ligaments surrounding a joint.

    • Classification: Based on degree of ligament damage; includes mild, moderate, and severe.

  • Strain Definition: Occurs from excessive stretching of muscles and fascia; may involve tendons.

    • Painful due to presence of nerve endings in joint areas.

  • Manifestations for Both:

    • Pain

    • Edema (swelling)

    • Decreased function

    • Bruising

  • Diagnosis: Typically via X-ray.

  • Complications:

    • Avulsion fracture

    • Subluxation

    • Dislocation

    • Hemarthrosis (bleeding into a joint)

  • Treatment:

    • Usually self-limiting but may require surgical repair.

  • Nursing Management:

    • Health promotion includes warm-up exercises, stretching, strength, balance, and endurance exercises.

    • Acute care employs RICE:

    • Rest: Stop activity and limit movement.

    • Ice: Apply for 20-30 minutes; maintain for 24 to 48 hours.

    • Compression: Use an elastic bandage, starting distally and moving proximally.

    • Elevation: Keep the injured part elevated above the heart.

    • Analgesics for pain management.

Dislocation and Subluxation

  • Dislocation: Complete displacement or separation of joint articular surfaces; considered an orthopedic emergency.

    • Symptoms: Deformity, pain, tenderness, loss of function, swelling.

    • Complications include intraarticular fractures and avascular necrosis (death of bone tissue).

  • Subluxation: Partial or incomplete displacement of joint surfaces; symptoms are less severe.

  • Management Goals:

    • Realign the dislocated joint to its original position.

    • Treatment options include:

    • Closed reduction under anesthesia.

    • Open reduction followed by immobilization.

  • Nursing Care: Focus on pain management, joint protection, gentle range of motion (ROM) exercises, rehabilitation, and prevention of recurrent dislocation.

Carpal Tunnel Syndrome (CTS)

  • Definition: Compression of the median nerve at the wrist, often due to repetitive wrist movements.

  • Associated with conditions such as:

    • Trauma

    • Edema

    • Cancer

    • Rheumatoid arthritis

    • Hormonal influences.

  • Increased incidence noted in patients with diabetes, peripheral vascular disease (PVD), rheumatoid arthritis, and female gender.

  • Manifestations:

    • Impaired sensation, pain, numbness, weakness.

    • Clumsiness, atrophy, and dysfunction of the hand.

  • Prevention:

    • Identify risk factors, use adaptive devices, and make ergonomic changes.

  • Acute Care Management:

    • Rest/splints, physical therapy, corticosteroid injections, potential occupational changes, and surgery (open or endoscopic).

Rotator Cuff Injury

  • The rotator cuff consists of four muscles that stabilize the humeral head and assist with range of motion (ROM) and rotation.

  • Tear Etiology: Generally occurs due to aging, repetitive stress, or injury.

  • Symptoms: Shoulder weakness, pain, decreased ROM, and positive drop arm test result.

  • Diagnosis Method: Magnetic Resonance Imaging (MRI).

  • Treatment:

    • Conservative: Rest, ice and heat application, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, ultrasound, and physical therapy.

    • Surgical options: Arthroscopy or acromioplasty followed by a 6-week immobilization period and gradual resumption of passive exercises.

Meniscus Injury

  • Anatomy: The menisci are fibrocartilage structures in the knee, also found in specific joints like acromioclavicular, sternoclavicular, and temporomandibular joints.

  • Injury Mechanism: Often occurs with ligament sprains in sports due to shearing forces; degenerative tears common in older adults or those frequently squatting or kneeling.

  • Manifestations: Local tenderness, pain, effusion, sensations of “popping,” “clicking,” “locking,” or “giving way.”

  • Diagnosis Tool: MRI.

  • Treatment: Generally arthroscopic surgery.

Anterior Cruciate Ligament (ACL) Injury

  • Fact: Knee injuries account for over 50% of all sports injuries.

  • Diagnosis: Often through MRI.

  • Conservative Management:

    • Rest, ice, NSAIDs, elevation, ambulation with crutches as tolerated.

    • Aspiration of knee effusion, use of an immobilizer or hinged knee brace, and physical therapy.

  • Surgical Management: Typically involves reconstructive surgery.

Anatomy of Fractures

  • Fracture Definition: Disruption or break in the continuity of bone structure.

    • Causes: Primarily traumatic injuries, but may also arise from disease processes (pathologic fractures due to conditions like cancer or osteoporosis).

  • Types of Fractures:

    • Open vs. Closed: Open fractures have broken skin, while closed fractures have intact skin.

    • Complete vs. Incomplete: Complete implies a fracture through the entire bone while incomplete means it partly crosses the bone shaft.

Classification of Fractures

  • Directional Types:

    • Linear, oblique, transverse, longitudinal, spiral.

  • Displacement:

    • Displaced: Bone ends separated.

    • Nondisplaced: Periosteum intact with aligned bone.

Fracture Manifestations

  • Signs typically include:

    • Edema and swelling.

    • Pain and tenderness.

    • Muscle spasms.

    • Deformity.

    • Contusion and loss of function.

    • Crepitation (grating sound).

    • Guarding (protective response to injury).

Influencing Healing Factors

  • Factors that influence fracture healing include:

    • Displacement and fracture site.

    • Blood supply adequacy.

    • Injuries to local tissues.

    • Effectiveness of immobilization.

    • Presence of internal fixation devices.

    • Infection risk.

    • Nutritional status.

    • Age of the patient.

    • Smoking habits of the patient.

Complications of Fracture Healing

  • Delayed Union: The prolonged healing time.

  • Nonunion: No healing occurs.

  • Malunion: Healing occurs but in an incorrect alignment.

  • Goals of Treatment:

    • Anatomic realignment (reduction)

    • Immobilization to maintain alignment

    • Restoration of near-normal function.

Fracture Reduction Methods

  • Closed Reduction: A non-surgical treatment involving manual realignment of bone fragments; typically requires traction and is done under anesthesia.

  • Open Reduction: Involves surgical intervention with internal fixation devices (wires, screws, pins, plates, rods or nails), which carries risks such as infection but facilitates early ambulation and reduces immobility risks.

Traction Techniques

  • Definition: Application of a pulling force to an injured or diseased body part.

    • Purposes:

    • Reduce pain and muscle spasms.

    • Immobilize joints.

    • Treat fractures or dislocations.

    • Address pathologic joint conditions.

    • Two main types:

    • Skin traction (short-term)

    • Skeletal traction (long-term).

Casts and Immobilization

  • Casts: Temporary devices after closed reduction to allow normal activities while maintaining immobilization.

    • Common materials: Plaster of Paris and Fiberglass.

  • Types of Casts:

    • Short arm cast

    • Long arm cast

    • Short leg cast

    • Long leg cast

Surgical and Interventional Approaches to Fractures

  • External Fixation: Creative usage of metal pins and wires that attach to external rods to apply traction and stabilize fractures with extensive soft tissue damage.

  • Internal Fixation: Surgical realignment with devices like pins, plates, or rods for stabilization.

  • Drug Therapy:

    • Muscle relaxants, antibiotics (especially for open fractures), and vaccination considerations for tetanus and diphtheria.

Nursing Assessment in Musculoskeletal Injuries

  • Subjective Data: Collection of health history, medications, surgeries, or treatments undergone.

  • Objective Data: Review of systems including:

    • Skin, cardiovascular, neurovascular, musculoskeletal systems.

  • Importance of neurovascular status assessments post-injury, especially distal to the injury.

Clinical Problems and Planning

  • Identified problems include:

    • Musculoskeletal issues.

    • Risk for infections.

    • Pain management needs.

  • Goals of care involve:

    • Successful healing without complications.

    • Adequate pain relief.

    • Quality rehabilitation potential.

Preoperative and Postoperative Care

  • Preoperative Care: Involves preparing the patient for surgery and ensuring understanding of immobilization, assistive devices, and activity limitations.

  • Postoperative Care: Includes monitoring vitals, neurovascular status, and overall care with focus on pain management and prevention of thromboembolic complications.

Nursing Management for Specific Fractures

  • Ambulation Training: Reinforcing physical therapy instructions, teaching use of assistive devices, pain management protocols.

  • Incidence and Management of Complications:

    • High risks of complications particularly with open fractures or those impacting vital organs (e.g., pelvic fractures, hip fractures).

Complications from Fractures

  • Direct Complications:

    • Bone infection

    • Nonunion or malunion

    • Avascular necrosis.

  • Indirect Complications:

    • Compartment syndrome

    • Deep vein thrombosis (DVT)

    • Fat embolism

    • Rhabdomyolysis

Fat Embolism Syndrome (FES)

  • Definition: Systemic fat globules released into circulation post-fracture; common with long bone fractures.

  • Symptoms: Include chest pain, tachypnea, clinical changes leading to acute respiratory distress syndrome (ARDS).

  • Management: Involves hemodynamic stability measures and careful handling of long bone fractures to prevent dislodging fat droplets.

Rhabdomyolysis

  • Definition: Breakdown of damaged skeletal muscle releasing myoglobin into circulation obstructing renal tubules, leading to acute tubular necrosis (ATN).

  • Assessment: Dark-reddish brown urine and renal function testing to identify acute kidney injury (AKI).

Audience Response Questions

  1. Case Scenario: A plaster splint applied to a fractured tibia is leading to increased pain not relieved by bandage loosening. Initial Nursing Action:

    • Perform neurovascular assessment of the foot (correct answer).

  2. Another Scenario: Instructions for a patient with a severely sprained ankle prior to discharge include:

    • Apply cold for 20 to 30 minutes with breaks of 10 to 15 minutes during the first two days (correct answer).

Traumatic and Surgical Amputation

  • Definition: Traumatic removal of an extremity or surgical removal for conditions causing necrosis or infections.

  • Assessment focuses on vascular and neurological conditions pre and post-amputation.

  • Nursing goals include satisfactory pain management and rehabilitation potential, coping with body image changes.

Joint Surgeries Overview

  • Various types of common joint surgeries include:

    • Synovectomy: Removal of synovial membrane to alleviate pain and improve ROM in inflammatory conditions like RA.

    • Osteotomy: Surgical removal of bone slice to correct deformity, manage weight-bearing, and relieve pain.

    • Debridement: Removal of bone/cartilage debris via fiberoptic arthroscope in outpatient settings.

    • Arthroplasty: Joint reconstruction or replacement for conditions leading to significant pain and diminished function.

    • Total Joint Arthroplasty: Specifically total hip (THA) and total knee arthroplasty (TKA) involving implants to restore functionality.

Complications of Joint Surgery

  • Key complications to monitor for include infections, deep vein thrombosis (DVT), and potential prosthesis loosening requiring vigilant postoperative care and prophylaxis measures.